Rescue ERCP after delayed migration of a lumen-apposing metal stent following endoscopic ultrasound-guided choledochoduodenostomy

Endoscopic retrograde cholangiopancreatography (ERCP) can be challenging in patients with altered anatomy or luminal narrowing. Endoscopic ultrasound-guided biliary drainage (EUS-BD) by placement of a lumen-apposing metal stent (LAMS; Hot-Axios; Boston Scientific, Marlborough, Massachusetts, USA) has emerged as an effective technique to allow biliary access after failed ERCP in a high-volume center [1].

A 46-year-old woman was referred to our hospital for acute cholangitis during chemotherapy for pancreatic cancer. She had undergone previous (5 weeks) EUS-BD with LAMS after two failed ERCPs in a peripheral hospital. Computed tomography showed migration of the LAMS distal flange within the duodenal wall, without evidence of perforation. Duodenoscopy confirmed correct position of the proximal flange within the duodenal bulb, and contrast swallow showed no extravasation of contrast medium or communication with the biliary tree. Normal papilla was identified in the second duodenum. A new ERCP achieved easy common bile duct (CBD) cannulation. Cholangiogram showed a dilated CBD, no evidence of bile leakage, and a neoplastic distal stricture. At fluoroscopy, the LAMS distal flange was clearly outside the biliary tree ([Video 1]). A fully covered metal stent was delivered across the neoplastic stricture and LAMS removal was performed. Contrast flushing across the duodenum did not show any leak; thus, the entry port was left open. The patient improved and was discharged 2 days later.

Video 1 The distal flange of the lumen-apposing metal stent was outside the biliary tree.

This is the first case of rescue ERCP for LAMS migration after EUS-guided choledochoduodenostomy. Limited data on long-term follow-up after LAMS deployment are available [2] and no randomized trial has been conducted. Caution should be used when deciding on EUS-BD after failed ERCP [3]. The best option is probably to refer the patient to a high-volume hospital, as LAMS may induce serious complications. Expertise in interventional endoscopy and therapeutic EUS is important because one could be the rescue therapy of the other.

Endoscopy_UCTN_Code_CPL_1AL_2AC FB

• References

• 1 Attili F, Rimbas M, Galasso D. et al. Fluoroless endoscopic ultrasound-guided biliary drainage after failed ERCP with a novel lumen-apposing metal stent mounted on a cautery-tipped delivery system. Endoscopy 2015; 47 (Suppl. 01) E619-E620
• 2 Park DH, Jang JW, Lee SS. et al. EUS-guided biliary drainage with transluminal stenting after failed ERCP: predictors of adverse events and long-term results. Gastrointest Endosc 2011; 74: 1276-1284
• 3 Jain D, Shah M, Patel U. et al. Endoscopic ultrasound guided choledocho-enterostomy by using lumen apposing metal stent in patients with failed endoscopic retrograde cholangiopancreatography: a literature review. Digestion 2018; 98: 1-10